Published May 20, 2002
I was wondering if anyone has any ideas on healing a stage three ulcer.
It is located on the bunion of a 83 year old patient. She is IDDM, and currently her treatment is panafil. medicare will not pay for a regranulation therapy. Any ideas? :confused:
Gotta love medicare sometimes.
I have never gotten a wound heal to heal using using panafil...(but the Reps say good things about it.)
If there is NO infection I have had good luck using regular duodermif it is a dry wound and duoderm granuals covered with duoderm if it is wet. The 'trick' to using duoderm on a dry wound is to NOT change it until you absolutely have to, it needs to get squishy and very slightly (again, NO infection) smelly.
I am also a BIG believer in good old fashoned wet to moist dressings, they take time to do the job tho.
If the wound is on the plantar surface, off-loading the foot is essential for healing. Keeping the patient non-ambulating with crutches (OK, I realize she's 83...) or a wheelchair. Otherwise, if the wound is on the side of the foot, can pressure relief be improved with a padded ankle-foot orthosis, (multi-podus boot)?
Have you established the patient's healing potential? How's her nutrition, weight stability, albumin, pre-albumin? Control of blood sugars, HgbA1c? Control of other co-morbidities, hypertension, CHF?
Have non-invasive vascular studies been performed? The presence of distal pulses (dorsalis pedis or post. tibialis) in the diabetic foot aren't necessarily sufficient evidence of adequate in-flow. In the individual with diabetes, an ankle-brachial index may be falsely reassuring. Often results can display ratios greater than 1.0 indicating the pressure in the foot is higher than the arm, likely due to non-compressable calcified distal vessels. Plethysmography or toe pressures can be very helpful in assessing arterial flow in the diabetic foot.
I actually like Panafil. Lately, I've been using it more than Accuzyme or Santyl.
Remember, there is significant evidence that suggests regular agressive surgical debridement reduces the healing time of chronic wounds. Are you able to have the patient seen by a podiatrist or other surgical specialist with competency in advanced wound management?
Rand Feinstein, RN, PA-C, CWCN
(mine are anyway)
I to love occlusion. Hydrocolloids (ie, Duoderm) often do the trick. It's that whole, keep it covered and protected, warm and moist and let the body clean it up/heal it up, type of thing.
However, I've seen patients get worse when occlusion has been tried on an ischemic wound. Best to know the etiology of the non-healing tissue before treating it.
Rand, This patient is T-19 and family doesn't want to do anything like sending her to a podiatrist or have any more tests done on her. Isn't that awful? Anyway, right now the wound specialist came up with wet to dry!!! Thanks for replying. If that doesn't work, we'll try occlusion.
"T-19" What's that?
Wet to dry recommended by a wound specialist!!??!!
If the patient has sensation in the foot with the wound, then true wet to dry (place a wet gauze dressing on the wound, let it dry then remove it...) is, in my opinion, inappropriate. At a minimum it it might be considered masochisitic. There are many other more appropriate dressings then wet to dry, unless you're really interested in non-selective debridement and the foot is insensate.
I'd refer the "specialist" to this discussion. Most current wound care text recommend against using wet to dry dressings.
T-19 is a welfare type of insurance coverage with far too many limitations, I moisten wet to dry dressings before removal. As the wet is drying on the wound, it pulls the exudate and dead tissue into the dressing. Moistening it with a little NS will not affect healing. I too have seen wet to dry pulled off and I thought it was painful. the woman has no sensation though. I will tell our specialist about your thoughts and ideas. Thanks, Gilda
P.S. What is off- loading the foot? She in not ambulatory she is post RAKA
My 19 year old son has started working concrete construction for the summer. Today, he got concrete/lime on his legs and could'nt rinse for 2 hours... by the time he got home he was in tears and his legs looked skinned in some parts. I quickly got him in the shower and told him to wash off best he could. I then poured hydrogen peroxide on him, then applied antibiotic ointment, then wrapped his legs in gauze. Is this ok or is there something else I can do for him? He is a tough guy but this is really hurting him. Should I remove the guaze and let it "breathe" tomorrow? Thank you in advance for any advice you may have. I am a student.....didn't plan on practicing on my own son.
I agree that moistening the gauze before removing it won't necessarily affect healing, but allowing the dressing (and the wound) to dry out will.
Something else to consider is the frequency of the dressing changes. Is the advantage of low cost gauze and saline off set by the labor cost of bid or tid dressing changes?
Off loading, is another way to describe removing pressure, (ie, managing tissue loads...). Is there a pressure component in the etiology of this wound? If not, what is the cause?
Not sure of the best approach of a likely chemical burn. Is this a workman's comp case? I'd suggest to your son that he inform his employer STAT. If they're professionals in the business, they should have some prior experience with this concern or could recommend an industrial clinic for appropriate medical advice.
Cynthia, I'm glad Rand replied to you. I am not in that area of expertise and know very little about chemical burns. Sorry. I hope your son gets the right treatment. Gilda
Diabetic neuropathy is the cause. Do you think changing the bandage BID or TID would be better? Of course not with wet-to-dry as it would not be dry by then. Too bad there isn't a web site that just addresses wound care!
Thank-you again Rand, Gilda
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